Family of Origin
1. Identify your major caregivers
Name
Relationship
_________________________________
_____________________________
_________________________________
_____________________________
_________________________________
_____________________________
_________________________________
_____________________________
_________________________________
_____________________________
2. List the birth order of the children in your family. Use a noun or adjective to describe
each person. Include yourself and deceased siblings. (Indicate if a sibling is deceased)
Sibling
Age
Descriptive noun or adjective
_____________________
______
_____________________________
_____________________
______
_____________________________
_____________________
______
_____________________________
_____________________
______
_____________________________
_____________________
______
_____________________________
_____________________
______
_____________________________
Number of children in your family: __________
Your rank in birth order: ____________
If you were adopted, at what age were you adopted? __________________
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3. List other adults who were involved in your childhood. Use a noun or adjective to
describe each person.
Adult/Relationship
Description
_____________________________
____________________________
_____________________________
____________________________
_____________________________
____________________________
_____________________________
____________________________
_____________________________
____________________________
_____________________________
____________________________
Parental Information
4. Is your mother living? Yes _____ No _____
If your mother is deceased, how old were you at the time of her death? ______
If the person you are identifying as your mother is not your biological mother, identify
your relationship to her. __________________________________________________
_______________________________________________________________________
5. 4. Is your father living? Yes _____ No _____
If your father is deceased, how old were you at the time of his death? ______
If the person you are identifying as your father is not your biological father, identify your
relationship to him. __________________________________________________
_______________________________________________________________________
6. If your parents were living during your childhood, were they
separated ___________ divorced ____________ living together _______________
If they were separated or divorced, at what age were you when they
separated ___________
divorced _____________
If your parents are living, what is their current marital status? ________________
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7. What were/are the educational levels and occupations of your parents?
Mother: Education: _______________________________________
Occupation: ______________________________________
Father: Education: ________________________________________
Occupation: _______________________________________
Early Family Relationships
8. Describe the physical, financial, and emotional situation of your parents at the time of
your birth or adoption.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
9. Describe the relationship that existed between your mother and father at the time of
your birth or adoption.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
10. Describe how your mother felt at the time of your birth or adoption.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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Describe how your father felt at the time of your birth or adoption.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
11. Describe the relationship that existed between your mother and father during your
childhood.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Childhood Memories and Parental Relationships
12. Before answering, close your eyes and image yourself as a child being in the physical
presence of your mother. After describing your mother, close your eyes and image again
yourself as a child being in the physical presence of your father.
List nouns and adjectives to describe your mother:
Positive
_____________
______________
Negative
_____________
____________
_____________
______________
_____________
____________
_____________
______________
_____________
____________
_____________
______________
_____________
____________
_____________
______________
_____________
____________
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List nouns and adjectives to describe your father:
Positive
_____________
______________
Negative
_____________
____________
_____________
______________
_____________
____________
_____________
______________
_____________
____________
_____________
______________
_____________
____________
_____________
______________
_____________
____________
Childhood Memories of Your Mother
13. Describe the happiest time you remember with your mother.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
14. Describe the worst time you remember with your mother.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
15. What did you want from your mother that you never received or she never did for
you? (Example: That she would love me as I was.)
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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16. As a child, what did you do to get approval from your mother?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Childhood Memories of Your Father
17. Describe the happiest time you remember with your father.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
18. Describe the worst time you remember with your father.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
19. What did you want from your father that you never received or he never did for you?
(Example: That he would support me in my decisions.)
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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20. As a child, what did you do to get approval from your father?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Childhood
21. Describe your earliest memory. What was your age at the time?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
22. When you think of yourself as a child, how old are you? _____________
23. Describe yourself as a child?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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24. Describe feelings you had as a child. These may include feelings such as being sad,
mad, glad, or scared or feeling of shame, guilt, empty, and/or lonely.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
25. What was your favorite childhood story? This can include stories such as a fairly
tale, book, television show or movie.
________________________________________________________________________
Describe the theme of your favorite story and how you related to each of the main
characters.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
26. Identify the people you felt close to in your childhood.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
27. As a child, was it easy or difficult to make friends? ___________________________
Why do you feel it was easy or difficult making friends?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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28. As a child, did you have nicknames? Yes ______ No _______
If you had nicknames, what were your nicknames and who gave them to you?
________________________________________________________________________
________________________________________________________________________
H. Current Relationship With Major Caregivers
29. Describe the relationship you have with your mother today.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Describe the relationship you have with your father today.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
30. If you had other major caregivers, identify the major caregiver (s) and describe your
current relationship (s).
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
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Reflections
31. Reflect on your childhood and your life today. In what ways would you and your life
be different today if you had had functional parents?
________________________________________________________________________
________________________________________________________________________
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